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Culture change through patient engagement

Author Information

Bettyanne Grant is a unit-based educator and clinical nurse IV, and Sandra H. Colello is a nurse manager at Maine Medical Center in Portland, Me.

GAPS IN COMMUNICATION can precipitate a cascade of events that may expose patients to potential harm and needless expense. As nurses on a fast-paced unit caring for complex patients, we realized it was time to challenge a long-standing practice of giving shift report away from the bedside. By changing to bedside report, we'd lessen the chances of missing information while letting patients and family participate in care. We believed the change would let us be more patient-centered.

It's been almost 3 years since the inception of the bedside report, which we described in "Engaging the Patient in Handoff Communication at the Bedside" in Nursing2009.1 We've grown in our practice since then, and our patients are empowered as partners in their care. This article describes the challenges we faced and our positive results.

Choosing a model of change

We recognized that change is challenging. After a thorough literature search, we decided to employ Lewin's change model to facilitate our practice change.2 We also acknowledged that we had to provide the staff with the opportunity to be involved in the change to ensure success.

We identified a core group of staff who would be instrumental in fostering a dramatic change in our nursing culture. The literature that directed our decisions also provided us with tools and information to implement a practice change.

We've encountered some stumbling blocks along the way. First, we had to acknowledge that communication is essential when motivating others to change. We again used Lewin's change theory. We believe it helped us to be successful because it involved planning and gathering facts before proceeding to implementation.2

The information shared in a taped report can be redundant, biased, inaccurate, outdated, and a poor use of a nurse's time.2 Rather than listening to taped report, nurses found that giving and receiving report at the bedside made better use of their time. Not only was it easier to prioritize patient care when they made earlier assessments, but it also provided an opportunity to address safety issues such as fall risks, skin assessments, and communication problems with the patient and family.

The report consists of a brief description of the circumstances that precipitated the patient's admission, medical diagnosis, and any other relevant information such as vital signs, pain intensity rating, patient complaints, and diagnostic study results that would impact patient care immediately.

Bedside report also lets nurses assess the patient as part of a team and negotiate appropriate recommendations for care. We briefly used a template or checklist but soon found that we can rely on the electronic care plan, the patient, and teamwork to produce positive outcomes. We've been able to stay below the national benchmark for falls and pressure ulcers and have improved pain management for our patients.

The bedside report offers a valuable educational opportunity for both nurses and patients. By collaborating, nurses and patients can develop an appropriate plan of care addressing issues such as pain management and meaningful discharge goals.

Bedside's not always best

Although most information can be shared at the bedside even in a semiprivate room, many nurses had concerns about how to handle sensitive information while maintaining Health Insurance Portability and Accountability Act (HIPAA) standards. Patient health histories are documented in patient records kept at the bedside so they are readily available for nursing staff. After careful consideration, we decided that personal or private information, including HIV/AIDS or hepatitis C status, should be shared privately away from the bedside.

Often it's difficult to decide who should hear information at the bedside. If patients are to be involved in their plan of care, clearly they should be at the center of the report. But when families or guests are present at the change of shift, nurses must be careful to include only those the patient wants to include. Because HIPAA violations could occur, we put much work into helping staff use language and develop skills to ensure patient confidentiality. Staff were encouraged to share their concerns and asked to offer suggestions to promote the partnership experience.

For example, nurses ask visitors to step out of the patient's room briefly during patient report. This way the patient doesn't feel pressured to ask them to leave. If the patient speaks up and asks the visitor to remain, then the report can proceed. In these cases, nurses can be more confident that the patient isn't in a difficult situation, such as an abusive intimate partner relationship. On the other hand, if the patient remains silent and lets the guests leave, nurses can be confident that the patient agrees with the request. It's important to relieve the patient of the burden to decide who can stay for the report and who can't.

We also identified other circumstances when sharing information at the bedside may not be appropriate. For instance, we don't disturb patients for report if they've been awake all night and have finally fallen asleep. Patients who are potentially disruptive or confused may not be included in a report either. Nurses need to use their professional judgment when deciding whether to include a particular patient in the bedside report.

The staff created a video to demonstrate an appropriate bedside report and help other units develop bedside report.

Generational concerns

Nursing culture is well ingrained in day-to-day practice, and for more experienced nurses, changes to familiar practices can often be difficult. Many believed that information shouldn't be shared with the patient and family. Others felt that this process would take too long and would involve too many interruptions from the patient, such as requests for assistance to the bathroom and pain medications.

Some nurses felt that it was their job to be the keeper of information; they didn't feel comfortable empowering the patient and thereby relinquishing control of this part of their practice. Novice nurses felt threatened by more experienced nurses who were resistant to change and were unsure of how to get them to engage in the bedside report.

As the nurses moved through the transition, they developed new skills that began with simply walking into the room and introducing themselves and letting the patient know that the outgoing nurse was going home. It wasn't long before the reluctant nurses engaged in the reporting process at the bedside. Once they were drawn into the process, they began to see the benefits of bedside report, such as time saved, safety catches, and prioritized patient care. Novice nurses just beginning their practice have easily adopted the bedside report as a routine part of patient care because they haven't known any other report practice.

Cultural shift

Bedside report is becoming standard practice for all units of the hospital, including the ED. When patients are transferred from unit to unit, however, the phone report is still the most practical way to share report. We're currently working on an interdisciplinary sign-out tool that will help to ensure that the most recent and complete information is shared with the receiving nurse.

Now, 3 years after we began, we're well on our way to a complete change in culture. The process has become a part of the daily routine, with these benefits to patient and staff:

* through early prioritization of care, improved patient outcomes such as decreased falls and saved time, resulting in reduced overtime

* collaborative patient safety assessments

* professional communication between shifts

* enhanced patient and nursing satisfaction, as seen in surveys taken every 6 months.

We continue mentoring other units and facilities in the development of partnership rounds as well as promoting the development of better processes for handoff communication overall. By being open to change, we've improved the handoff process and our patients' safety.

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